1. Are you satisfied with the products and services offered to you?
Yes No
(If not, please explain)?
Type your answer here.

2. Do you conduct regular business with this chapter?
Yes No
(If not, please explain)?
Type Your answer here.

3. Are you satisfied with the service/assistance you receive from this local Chapter?
Yes No
(If not, please explain)?
Type your answer here.

4. Would you be interested in On-site Training?
Yes No

5. Are you currently receiving newsletters and correspondence from this local Chapter?
Yes No
If not, would you like to be added to our database?
Yes No

6. Would you like for us to send you a free catalog?
Yes No

Company Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone Number:
Email address: